1. Name of the Applicant 2Father's/Husband's Name 3Address (a) Permanent (b) Present 4Age (in years) 5Type of certificate is required ( Identity/ Nativity/ Legal heir/ Caste/ Income/ Resident/ Nationality/ Valuation/ Solvency/ Procession and any other certificate ) 6. Purpose for which the certificate is required 7. Particulars on the basis of which the certificate is required 8. List of documents and affidavit. ( where necessary) (2) (1) Application Form for Issue of a Miscellaneous Certificate R.I. Office FORM NO. - 1 ( See Rule - 4 ) Annexure - II (3)Government of OrissaRevenue & Disaster Management Department Published on National Portal of India (india.gov.in) IdentityNativityLegal HeirCasteIncomeResidentNationalityValuationSolvencyProcessionOther 9.DECLARATIONI Sri/Kumari/Smt.son/daughter/wife ofSriResident of villageP.O. P.Sin the district ofdohereby declare that the information and particulars stated aboveare true to the best of my knowledge and belief and that they are exhaustive and I have not suppressed andany fact in case it is detected later on that any of the facts stated above are wrong or that I have suppressedsome material facts I shall be liable for prosecution under the relevant law.Date Place Signature of the Applicant Published on National Portal of India (india.gov.in)
